CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB071

Cpcplab071 Colorectal Cancer Screening 01 15 25

Defines reimbursement and coding guidance for laboratory-based colorectal cancer screening tests (FIT, gFOBT, FIT-DNA/Cologuard, methylated Septin 9/ColoVantage) for asymptomatic individuals, including age-based coverage limits and non-reimbursable techniques.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCpcplab071 Colorectal Cancer Screening 01 15 25

Policy CodePolicy CPCPLAB071

Change TypeRevised (04/29/2024) and Added (11/01/2023)

Effective DateJan 15, 2025

Next Review Date

Key ActionProviders must submit claims using valid HIPAA code sets and appropriate industry-standard coding guidelines; claims are subject to code edit protocols and may require additional documentation.

SourceLink

POLICY UPDATE CHANGES

04/29/2024: Document updated with literature review; reimbursement info revised to remove direct visualization tests (colonoscopy, CT, flexible sigmoidoscopy) from #1 and removed colon capsule endoscopy from #4; references revised.

11/01/2023: New document created; prior content moved from CPCPLAB007 Preventive Screening in Adults.

3Reimbursable test categories listed (FIT, gFOBT, FIT-DNA)

3Explicitly not reimbursable items (Septin 9, anal cytology, anal HPV)

45-75Covered age range

Coverage Summary

Defines reimbursement and coding guidance for laboratory-based colorectal cancer screening tests for asymptomatic individuals, including age-based coverage limits and non-reimbursable techniques. BCBSOK implemented lab management reimbursement criteria for colorectal cancer screening; policy status is CURRENT. Effective Date/Plan Effective Date: 01/15/2025; Last review/Approval Date: 04/29/2024.

Key thresholds and coverage highlights

Age range45-75 years

FIT-DNA (Cologuard) frequencyOnce every 3 years

Preferred reimbursable testsFIT (fecal immunochemical test) or gFOBT

Coverage stancemixed (some tests reimbursable; some explicitly not reimbursable)

Covered test categoriesReimbursable: FIT, gFOBT, FIT-DNA (Cologuard)

Medical-Necessity Criteria

Reimbursable Colorectal Cancer Screening - Asymptomatic Individuals 45-75 years

Reimbursable when ALL of the following are met:

Asymptomatic: Individual is asymptomatic
Age: Individual age is 45 to 75 years45-75 years
Modality: Screening modality is fecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT)
FIT preferred

Coding

Procedure / Test Codes referencedmixed

81327	Methylated SEPT9 (ColoVantage / Epi proColon) — listed in document as not reimbursable
81528	FIT-DNA (Cologuard)
82270	gFOBT (guaiac fecal occult blood), per single specimen
82274	FIT (fecal immunochemical test), per single specimen
87624	HPV detection — listed in document codes; anal HPV screening is listed as not reimbursable
87625	HPV detection (other)
88112	Cytopathology, screening (anal pap smear referenced as not reimbursable)
0500T	Multitarget stool DNA test — alternate coding referenced as an alternative to FIT-DNA (Cologuard)

Provider Actions

Billing Rule

Code submission and documentation

Providers must submit claims using valid HIPAA code sets and appropriate industry-standard coding guidelines. Claims are subject to code edit protocols and claim review; additional documentation may be requested. Follow industry coding resources and guidance when preparing submissions.

Use HIPAA-approved code sets and industry-standard coding guidelines (CPT, HCPCS, ICD-10, UB, NDC, DRG, CMS NCCI rules).
Claims are subject to code edit protocols and claim review against benefit coverage, provider contracts, medical and coding policies.
Submit additional documentation upon request to support medical necessity and coding.

Prior Authorization

Plan-specific applicability

Not all requirements in this policy apply to every product. Providers should review applicable plan documents (Certificates of Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents) for eligible coverage, prior authorization requirements, and product-specific rules.

Background & Evidence

BCBSOK implemented lab management reimbursement criteria for colorectal cancer screening that clarifies preferred and reimbursable laboratory modalities, identifies non-reimbursable tests and techniques, and specifies age limits; not all requirements apply to every product. The policy clarifies that FIT (fecal immunochemical test) is preferred and that reimbursable laboratory screening modalities include FIT, gFOBT and FIT-DNA (Cologuard) with specified frequency; it specifies that use of methylated Septin 9 (ColoVantage) and certain anal screening techniques are not reimbursable, and that average-risk, asymptomatic individuals > 75 years are not eligible for reimbursable screening. Product applicability note: Not all requirements apply to each product; providers should review plan documents for eligible coverage and any prior authorization or product-specific rules.

Evidence and guideline references cited in the policy include the American Cancer Society (ACS), U.S. Preventive Services Task Force (USPSTF), American College of Gastroenterology (ACG), the U.S. Multi-Society Task Force on Colorectal Cancer, multiple primary studies (including prospective and diagnostic accuracy studies), and FDA documents (e.g., SSED and PMA materials).

Definitions: Asymptomatic — Individual without symptoms suggestive of colorectal cancer (policy applies to average-risk screening).

Revision History

04/29/2024revisedLatest

Document updated with literature review; Reimbursement Information revised to remove direct visualization tests (colonoscopy, computerized tomography, flexible sigmoidoscopy) from item #1 and removal of colon capsule endoscopy from item #4; references revised. Plan Effective Date listed as 01/15/2025.

11/01/2023added

New document created; colorectal cancer screening was previously addressed in CPCPLAB007 Preventive Screening in Adults.

01/15/2025effective_date